Individual and population burdens of major trauma in the Netherlands

111Bulletin of the World Health Organization | February 2008, 86 (2) Objective To assess the impact of major trauma on individual and population health. Methods Data from a regional trauma registry were used, including all trauma fatalities and nonfatal severely injured patients (injury severity score >15) in 1999 and 2000. The impact of fatalities was expressed in terms of years of life lost (YLL). The impact of severe injury on survivors was expressed in terms of years lived with disability (YLD). Disability weights were based on quality of life at 15 months after injury, measured with EuroQol-5D. Disability-adjusted life years (DALYs) were calculated as the sum of YLLs and YLDs. Findings There were 567 fatalities and 335 survivors. At the individual level, trauma fatalities (32 YLLs per patient) and nonfatal cases of major trauma (12 YLDs per patient) both led to a substantial loss of healthy life years. Each victim of major trauma contributed an average of 25 DALYs to the burden of disease. At the population level, major trauma caused 10 DALYs per 1000 inhabitants. Road- traffic injury was the main contributor to the population burden of major trauma. Conclusion Both at individual and population levels, major trauma has a massive impact on health. Most severely injured victims of road-traffic crashes reach the hospital and have good chances of survival. Injury prevention and trauma care policies should aim at further reduction of both fatalities and permanent consequences among survivors. Bulletin of the World Health Organization 2008;86:111–117. Une traduction en français de ce résumé figure à la fin de l’article. Al final del artículo se facilita una traducción al español. Individual and population burdens of major trauma in the Netherlands Herman R Holtslag,a Eduard F van Beeck,b Rob A Lichtveld,c Loek PH Leenen,d Eline Lindeman a & Chris van der Werken d .ةلاقلما هذهل لماكلا صنلا ةياهن في ةصلاخلا هذهل ةيبرعلا ةمجترلا a Rehabilitation Center De Hoogstraat, Department of Rehabilitation and Sports Medicine; and Rudolf Magnus Institute of Neuroscience, University Medical Centre, Utrecht, the Netherlands. b Department of Public Health, Erasmus MC, University Medical Centre, Rotterdam, the Netherlands. c Regional Ambulance Services, Utrecht, the Netherlands. d Department of Surgery, University Medical Centre, Utrecht, the Netherlands. Correspondence to Herman R Holtslag (e-mail: H.R.Holtslag@umcutrecht.nl). doi:10.2471/BLT.06.033803 (Submitted: 7 June 2006 – Revised version received: 25 June 2007 – Accepted: 3 July 2007 – Published online: 17 December 2007 ) Introduction Injury is not only the leading cause of death in adults below the age of 45 years1 but also an important cause of functional limitations.2–4 As survival is a limited indicator of outcome, the focus in evaluations of medical interventions has shifted to health-related quality of life. The combined impact of mortal- ity and morbidity resulting from injury is, however, largely unknown, but it can be quantified with the help of the disability-adjusted life year (DALY) methodology, developed by WHO and the World Bank.5 This methodology as- sesses the impact of diseases and injury in terms of years of life lost (YLL) in fatal diseases and years lived with dis- ability (YLD) in non-fatal diseases. The DALY methodology has been used as an assessment approach in the global burden of disease and injury study to set global priorities for health research and to assess global health trends.5–10 This tool can help decision-makers set priorities for prevention and evaluates the effectiveness and cost-effectiveness of health-care policies. Its application depends primarily on the availability of representative and valid epidemiological data on diseases and injuries. Previous estimates of injury-related DALYs1,11 were based on statistical information in various databases of injury mortality and morbidity, which imposes several limitations.12 The DALY method has not previously been applied to major trauma, probably because combined data systems on fatalities and perma- nent consequences among survivors are scarce. The aim of this study was to quan- tify the burden of major trauma at the individual and population levels in the catchment area of our trauma-care centre in the Netherlands in the years 1999–2000. We investigated the im- pact on health in terms of burden of injury, YLD, YLL and DALYs. Patients and methods Patients The study was done at the University Medical Centre Utrecht (UMCU), in cooperation with the Utrecht Regional Ambulance Services. The UMCU is one of 10 level-1 trauma hospitals in the Netherlands, with a catchment population of 1.1 million with a popu- lation density of 813 inhabitants per square kilometre. Level-1 is a certifi- cation of the hospital about the cir- cumstances and skills for treating all kinds of trauma patients. All severely injured survivors in the province of Utrecht (i.e. an administrative part of the Netherlands with its own regional board of governors) are transported to this trauma centre. Utrecht is in the middle of the country in an urban-rural region. The comprehensive registration required for the study, would not have been possible in many other trauma centres. 112 Bulletin of the World Health Organization | February 2008, 86 (2) Research Burdens of major trauma in the Netherlands Herman R Holtslag et al. to include equivalent years of healthy life lost due to poor health or disability. To calculate DALYs for a particular cause of disease or injury in a popula- tion, the YLL is added to the YLD. In our study, YLL due to mortality from injuries were calculated by average life expectancy for specific ages and sex obtained from the Dutch standard life tables.18 YLD were calculated for each surviving patient by multiplying the residual life expectancy and the person’s loss of ability 15 months after injury.5 We used the classification of ex- ternal causes of injuries established by the WHO,1 distinguishing between unintentional and intentional injuries. Unintentional injuries are road-traffic injuries, accidental falls, fires, drowning, poisoning and others. It was not pos- sible to assess the consequences of non- fatal drownings and poisonings, because we did not include these patients in our trauma register. Intentional injuries are self-inflicted injuries, homicide or violence and war. This classification is the first step to allow comparisons with the global WHO database on diseases and injuries. We calculated YLL, YLD and DALYs at individual level (for each patient with trauma) and at population level (per 1000 inhabitants). The for- mer reflects the average impact on an individual, whereas the latter provides information about the burden to society in terms of population health. Calcula- tions were made using Microsoft Office Excel 2003. Results Patient and injury characteristics Fig. 1 describes the study group con- sisting of 567 fatalities (355 men, 212 women) and 335 severely injured long- term survivors (249 men, 86 women). The overall mean age of the victims of injury-related fatalities was 48.4 years (standard deviation, SD: 23.3), whereas that of the survivors was 37.7 years (SD: 17.1). Follow-up assessment took place between 12 and 18 months after trauma [with a mean of 451 days (SD: 47)]. The mean utility score was 0.69, with a standard deviation of 0.30, and 83 patients reported no limitations. One third of injuries were intentional. There were twice as many fatalities after self-inflicted injuries (suicide) than after road-traffic injuries. Twice as many men were involved in major trauma than were women (Table 1). Falls frequently caused fatal injuries, especially among women. Impact of major trauma at individual level Combining all injuries, the mean num- ber of YLL per patient after fatal trauma was 32, while the mean number of YLD per patient was almost 12 (Table 2). We found a mean of 25 DALYs lost for each patient. Intentional injuries resulted in substantially more DALYs (34 DALYs) per patient than did unintentional inju- ries (21 DALYs), while falls resulted in much lower than average YLL and YLD per patient, and homicide and violence, Over two years (January 1999 to January 2001) data on all non-natural deaths (prehospital, in-hospital and post- hospital) in the region were collected, in cooperation with forensic medicine specialists and representatives of the jus- tice department. This database provides validated personal and medical data (e.g. after autopsy) about the circumstances of the injury, injury localization and cause of death. In addition, all survivors over the age of 15 years with an injury severity score13 higher than 15 were ap- proached one year after the injury. The cut-off point of 15 is an international accepted standard by trauma surgeons.13 Patients with an injury severity score greater than 15 are defined as survivors of major trauma, an injury severity score of 75 is counted as unnatural deaths. The study protocol was approved by the medical ethics committee of the UMCU. Outcome assessment We used the EuroQol-5D (EQ-5D) as a generic instrument to measure health status. This instrument has been devel- oped and validated in samples of pa- tients from several European countries, including the Netherlands.14,15 It defines health along five dimensions: mobility, self-care, daily activities (such as work, study, housework and leisure activi- ties), pain or discomfort and anxiety or depression. Each dimension has three levels: no problem, moderate problem or severe problem. In the second part of the EQ-5D, the health status is recorded on a vertical visual analogue scale (VAS), ranging from 0 (worst imaginable health state) to 100 (best imaginable health state). The patients are asked to mark the point on the scale that they felt best reflects their current health state. A util- ity score (EQus) is calculated from the five EuroQol dimensions, ranging from 1 for perfect health to 0 for death. EQus can be though of as an objective measure of the utility and the EQvas more as a subjective impression of the patient.16 The EQus was used to calculate an empirically derived disability weight (1-EQus) – i.e. a summary measure of the severity of the permanent conse- quences of an injury or disorder.17 Methods DALYs are a measure of the health gap that extends the concept of potential years of life lost due to premature death Fig. 1. Flowchart of the injury-related fatalities and response of the severely injured patients (ISS >15) admitted to the University Medical Centre Utrecht from January 1999 to January 2001 Injury-related fatalities (n = 567) Death at the scene (n = 467) Severely injured survivors (n = 399) Lost to follow-up (n = 24) Death after admission (n = 100) Children <16 years (n = 40) Eligible severely injured survivors (n = 335), response rate 93% ISS, injury severity score. Research Burdens of major trauma in the Netherlands 113Bulletin of the World Health Organization | February 2008, 86 (2) Herman R Holtslag et al. Table 1. Fatalities and survivors after major trauma categorized on the basis of the WHO classification of external causes of injury, in the Utrecht region, the Netherlands, 1999–2000 Category of major trauma Fatalities (n = 567) Survivors (n = 335) Women Men Women Men Unintentional 120 204 83 232 Road traffic 40 111 63 173 Falls 66 54 18 42 Fire 3 3 – – Drowning 5 18 1 – Poisoning 3 3 – – Other unintentional 3 15 1 17 Intentional 92 151 3 17 Self-inflicted 78 128 2 6 Homicide and violence 14 23 1 11 Mean age (SD) 54.4 (26.4) 44.6 (20.4) 41.0 (19.1) 36.6 (16.3) SD, standard deviation. Table 2. Burden of injuries categorized on the basis of the WHO classification of external causes of injury per patient and per 1000 inhabitants, in the Utrecht region, the Netherlands, 1999–2000 Category of major trauma Individual level (per patient) Population level (per 1000) YLL YLD DALYs YLL YLD DALYs Unintentional injury 30.6 11.3 21.1 4.5 1.6 6.1 Road traffic 39.5 11.5 22.5 2.7 1.2 3.9 Falls 16.2 10.9 14.4 0.9 0.3 1.2 Drowninga 38.3 – 38.3 0.4 – 0.4 Other unintentional 37.2 9.1 25.1 0.5 0.1 0.6 Intentional injury 34.8 18.1 33.6 3.8 0.2 4.0 Self-inflicted 33.2 33.6 32.7 3.1 0.1 3.2 Homicide and violence 44.1 16.6 35.8 0.7 0.1 0.8 All injuries combined 32.4 11.7 24.7 8.3 1.8 10.1 DALYs, disability-adjusted life years; YLD, years lived with disability (survivors of major trauma); YLL, years of life lost (fatalities due to external causes of injury). a Nonfatal drowning was not registered as major trauma. as well as drowning, caused far higher than average YLL per patient. Impact of major trauma at population level For our trauma region, major trauma caused 10 DALYs per 1000 inhabitants per year (Table 2). Slightly more than 80% of DALYs were due to fatalities and just below 20% were caused by permanent disability among survivors. Road-traffic injuries were the major (40%) contributor to DALYs, due to the effect of high numbers of both fatal and nonfatal cases. Suicide and self-inflicted injuries ranked second, because they were the biggest cause of mortality. The population health burden of injuries, in terms of DALYs per 1000 inhabitants is characterized by large variation by type of injury and age (data not shown). Road-traffic injuries showed a peak among adolescents and young adults (15–30 years) with a level of almost 24 DALYs per 1000 inhabitants among 15–19 year olds. Self-inflicted injuries and violence were concentrated at somewhat older ages (20–50 years) with the highest level (19 DALYs per 1000 inhabitants) among the 45–49 years old. DALYs per 1000 inhabitants were highest among the (very) elderly (7 DALYs per 1000 inhabitants among people aged more than 80 years). We were able to break down the absolute numbers of DALYs in our region into three components: YLL due to on- scene mortality, YLL due to in-hospital mortality, and YLD due to permanent functional consequences among survi- vors (data not shown). For road-traffic injures, the proportion of DALYs caused by on-scene mortality was one-third (primary YLL). Another third were related to in-hospital mortality (second- ary YLL). The remainder were related to those surviving major trauma (YLD). The same tendency was observed for falls, but not for self-inflicted injuries, where mortality at the scene was re- sponsible for most (90%) of DALYs, and YLD (2%) hardly contributed to the burden of injury. Impact of road-traffic injuries Table 3 shows the differences in impact of the various types of traffic par- ticipants, both in absolute numbers of YLL, YLD and DALYs and expressed in DALYs per 1 billion km travelled. The road-traffic subgroup consisted of 151 fatal cases (111 men, 40 women) and 236 severely injured long-term survi- vors (173 men, 63 women). The overall mean age of the injury-related fatalities was 39.5 years (SD: 33.7), while that of the survivors was 35.8 years (SD: 31.5). There were almost three times as many men as women among both those that died and those that survived. Table 3 shows that car crashes produced the highest absolute numbers of YLL, YLD and DALYs, although the number of DALYs per 1 billion km travelled was below the average of all modes of transport. Car crashes contributed more than 50% of the YLL, 40% of the YLD, and 48% of the DALYs due to the high share (72%) in kilometres travelled with 114 Bulletin of the World Health Organization | February 2008, 86 (2) Research Burdens of major trauma in the Netherlands Herman R Holtslag et al. this mode of transport. Crashes of two-wheeled motor vehicle crashes, however, resulted in by far the highest number of DALYs per 1 billion km trav- elled, resulting in almost one quarter of the absolute number of DALYs despite this mode of transport accounting for a very low share (1.5%) of the total kilometres travelled. Discussion The aim of this study was to assess the impact of major trauma on health at the individual and population levels in our trauma care region in the Netherlands. At individual level, trauma fatalities (32 YLL per patient) and nonfatal ma- jor trauma (12 YLD per patient) both led to a substantial loss of healthy life years. Each person with major trauma contributed an average of 25 DALYs to the burden of disease. At population level, major trauma caused 10 DALYs per 1000 inhabitants. The strongest feature of our study was the use of the population-based regional registry of fatal and non-fatal injuries after major trauma, which was initiated by one of the coauthors.19 This registration system was implemented over the years 1999 and 2000, in co- operation with the regional ambulance services, forensic doctors, the local jus- tice department and all hospitals in the Utrecht trauma-care region. Tremendous efforts by many co-workers have led to a validated and almost complete regional data set on unnatural causes of death. Another strong feature was the use of individually derived disability weights, collected in a prospective cohort study with a high (93%) response rate among the survivors.20 The study was, however, subject to some limitations, such as the fact that children below the age of 16 years were excluded from the survivors. This exclu- sion was due to the lack of well validated instruments for measuring quality of life among children at the time of our study. There is still no consensus on this topic, although recent studies have shown that children more than 5 years of age could have been included as well and measured with the same instru- ment.21 Another potentially debatable issue is our assumption that outcome measurements at an average of 15 months after the injury represent a life- long situation. However, studies in the United States of America (USA), the Table 3. Burden of major trauma (DALYs per 109 km) resulting from road accidents (n = 387) by mode of transport, 1999–2000 YLL YLD DALYs Travelled (109 km) DALYs per 109 km Pedestrian 504 134 638 0.5 1276 Bike 1146 370 1515 2.0 758 TMV 1007 1041 2048 0.4 5120 Car 3089 1103 4193 19.4 216 Others 217 81 297 4.2 71 Total 5963 2729 8775 26.6 330 DALYs, disability-adjusted life years; TMV, two-wheeled motor vehicle; YLD, years lived with disability (survivors of major trauma); YLL, years of life lost (fatalities due to external causes of injury). United Kingdom and the Netherlands found no further improvement in functional activity after major trauma between 12 months and 18 months of follow-up,22–24 which supports our decision. A third debatable issue is the use of the EQ-5D, because it lacks a cognitive dimension, and thus under- estimates the impact on the quality of life of patients with brain injury. This limitation, together with the exclusion of children means that our estimates of YLD and DALYs due to major trauma are probably somewhat conservative. To assess the extent of this underes- timation we made some additional calculations. First of all, we estimated YLD among children below 16 years of age with major trauma (n = 40 in our sample), assuming the same aver- age utility loss (1-EQus) as youngsters 15–19 years of age, leading to an addi- tional 700 YLD. Second, we compared our data on loss of ability in patients with brain injuries (because of lack of the cognitive dimension of the EQ-5D) with disability weights obtained in a panel study.25 This showed an underes- timation of 0.06 per patient with brain injury, and an underestimation of 150 YLD among all patients with brain in- jury (n = 181) in our sample. Our addi- tional calculations show that we missed 850 YLD (0.2 per 1000 people), which means an underestimation of 20% of the YLD, or 4% of the DALYs. Our study focused on long-term consequences of patients with major trauma (injury severity score > 15) and made prior exclusions of patients with injury of low to moderate severity. We compared our results with a European study (including the Netherlands)26 on the burden of injury with broader inclusion criteria. This European study included all admitted and emergency care patients, and contrary to our study, included short-term disability as well. By applying this broader scope a YLD rate of 3 per 1000 inhabitants was found in the Netherlands. In our study focusing only on the long-term conse- quences of major trauma (injury sever- ity score > 15), a YLD rate of 1.8 per 1000 inhabitants was observed. This finding puts our results on YLD into perspective, showing the importance of major trauma. The global burden of disease and injury study in 1996, which led to global priorities for health research and to assess global health trends,5–10,27 was a milestone in the development of sum- mary measures of population health, as it established a single set of several hundred disability weights relating to 107 disorders, using the same evalua- tion method.5 One of the main findings was that injuries are among the lead- ing causes of death and disability for both sexes in high-income countries.1 Road-traffic injuries were the 10th most important cause of death and the ninth most important cause of the burden of disease; they were followed closely by self-inflicted injuries, falls and inter- personal violence. In the Netherlands, road-traffic injuries and home and lei- sure injuries have also been shown to contribute greatly to the burden of disease.25 In both, this Dutch study and the global burden of disease and injury study, the YLL were dominated by dis- eases of the circulatory system and by neoplasms, while the YLD were mainly caused by neuropsychiatric disorders. These three leading causes of DALYs represent 60% of the total burden of disease in the Netherlands. The same pattern has been found in the first study on burden of disease and injury carried out in Australia in 1996.9,10 Our study calculated that major trauma contrib- uted 10 DALYs per 1000 inhabitants Research Burdens of major trauma in the Netherlands 115Bulletin of the World Health Organization | February 2008, 86 (2) Herman R Holtslag et al. at population level, which is lower than ischaemic heart disease (17 per 1000 inhabitants), comparable with cerebro- vascular accidents and chronic lung disease, and higher than depression (7 per 1000), diabetes (6.5 per 1000), and almost equal to the sum of road-traffic accidents (4.7 per 1000), suicide (3.3 per 1000), and home and leisure ac- cidents (2.8 per 1000).11 A straightforward comparison of the results with the global burden of disease, the Australian and the Dutch studies is still difficult, as they used dif- ferent disease classifications and differ- ent data presentations (absolute num- bers or percentages). Researchers should try to standardize their data presenta- tion to improve comparability between studies. As a first standard in this field, we suggest the use of the WHO clas- sification of external causes of injuries. Secondly, we advise the following fur- ther distinction of road-traffic injuries: pedestrian, bike, two-wheeled motor vehicle, car, train and others. In present- ing the data, YLL, YLD and DALYs should be presented separately, and ab- solute numbers instead of percentages should be used. In addition, rates per 1000 inhabitants should be presented for all causes and rates per billion kilo- metres travelled for all separate modes of transport. This study has confirmed previ- ous findings showing the importance of road-traffic injuries as a public health problem, and has provided new information to the contributions of different types of road user in terms of YLL, YLD and DALYs (both in abso- lute terms as per 1 billion km). In our Dutch trauma region, in absolute terms the main contributors to YLL, YLD and DALYs resulting from road-traffic injuries were car occupants. Expressed per 1 billion km travelled; however, users of two-wheeled motor vehicles appeared to have by far the highest number of DALYs, more than half of it being caused by YLD. Nowadays, most serious road-traffic injuries are nonfatal. Most victims of major trauma caused by road-traffic crashes reach the hospital alive and have good chances of survival, which holds in particular for crashes involving two-wheeled motor vehicles. Our data indicate that crashes involv- ing both cars (high absolute numbers of DALYs) and two-wheeled motor vehicles (high numbers of DALYs per 1 billion km travelled) need further reductions. If policy measures are taken they should be evaluated in terms of reductions in YLL, YLD and DALYs. Evaluations of road-traffic policies based purely on mortality rates have become insufficient. They should include a measure of morbidity as well, such as that obtained using the DALY method. Detection of significant changes in YLL, YLD and DALYs (both in abso- lute terms and expressed per 1 billion km travelled) is helpful to assess the effectiveness of road-traffic policies and to define areas for research and further policy.28,29 Politicians and decision- makers involved in prevention efforts often focus on mortality rates to justify their policies, including those on speed limits, seat belts and safety helmets. But the increasing numbers of patients who survive a severe injury are probably to be found in the group with lifelong dis- abilities. We quantified this shift from fatalities to chronically disabling condi- tions with the DALY method, showing that it will result in a net health benefit of almost 21 years per patient saved [loss of 32 YLL per fatality minus 12 YLD per survivor (Table 2)]. It seems clear that this shift will lead to increases in the use of health services and related medical costs. The above shift in road- traffic crashes resembles developments in other fields of medicine. For ex- ample, a sharp reduction of the case fa- tality rate of acute myocardial infarction has led to increasing numbers of pa- tients with chronic heart failure and increasing demands on health care.30 Our data show that new invest- ments in road-traffic injury prevention and trauma care are highly needed but also that they will not suffice. In our trauma-care region, suicide and falls are two other major causes of DALYs. Suicide is by far the most important cause of trauma-related mortality in our region, most of its victims (90%) dying at the scene. In the Netherlands, over the past 20 years the suicide mortality rate has been stable at 10 per 100 000 person-years, where the road-traffic in- jury mortality rate dropped from 10 to 5 per 100 000 person-years. Both these national figures and our regional data show that suicide prevention seems a largely neglected area in Dutch health- care policies. Our regional data provide support for a recent call to initiate a national suicide prevention plan as a novel public health-priority issue in the Netherlands.31 Our regional data show the need of further reductions in the population burden of falls. Similar to people in- volved in road-traffic injury, most people who have falls reach the hospital alive, and both groups could therefore benefit greatly from improvements in trauma care. A health-policy strategy, combin- ing prevention and care innovations, has in the past been very successful in the reduction of road-traffic and fall- related mortality in the Netherlands32 and should be continued in the future. Major trauma is an important world- wide public-health problem in young individuals, with in-hospital case fa- tality rates in the past few decades declining to about 20%.33 Combining mortality and morbidity in the DALY method potentially improves the evalu- ation of trauma care. Both the YLL for those dying after arrival at the hospital and the YLD for those surviving with permanent consequences are essential measures of the effectiveness of trauma- care systems, rather than the YLL for those dying on the scene. Continuous regional, or better national, registries should be set up for fatal as well as non- fatal injuries, including their perma- nent consequences. This would allow improvements in trauma to be measured in terms of YLL, YLD and DALYs. Conclusions Both at individual and population lev- els, major trauma has a large impact on health. Applying the DALY method, we quantified the importance of road- traffic accidents as a public-health prob- lem in the Netherlands, and found a net health benefit of the shift from mortal- ity to disability. Most people severely injured in road-traffic accidents reach the hospital alive and have good chances of survival. The DALY method provides a unique perspective on health that integrates fatal and non-fatal outcomes, while still allowing the two classes of outcome to be studied separately. Injury control policies should aim to further reduce both the number of fatalities and the permanent consequences among survivors. ■ Competing interests: None declared. 116 Bulletin of the World Health Organization | February 2008, 86 (2) Research Burdens of major trauma in the Netherlands Herman R Holtslag et al. Résumé Poids pour les individus et la population des traumatismes majeurs aux Pays-Bas Objectif Evaluer l’impact des traumatismes majeurs sur la santé des individus et de la population. Méthodes On a utilisé les données tirées des registres des traumatismes régionaux, et notamment celles concernant tous les décès par traumatisme et les traumatismes graves non fatals (degré de gravité > 15) survenus entre 1999 et 2000. L’impact des traumatismes mortels a été exprimé en termes d’années de vie perdues (YLL). Celui des traumatismes graves sur les survivants a été formulé en termes d’années de vie vécues avec une incapacité (YLD). Les poids affectés aux incapacités étaient fonctions de la qualité de vie 15 mois après le traumatisme, mesurée par EuroQol-5D. Les années de vie corrigées de l’incapacité (DALY) ont été calculées en sommant les YLL et les YLD. Résultats On a recensé 567 accidents mortels et 335 accidents non mortels. Au niveau individuel, les décès par traumatisme (32 YLL par personne), comme les traumatismes majeurs non fatals (12 YLD par personne), ont conduit à une perte substantielle d’années de vie en bonne santé. Chaque victime d’un traumatisme majeur a contribué en moyenne pour 25 DALY à la charge de morbidité. A l’échelle de la population, les traumatismes majeurs ont entraîné 10 DALY pour 1000 habitants. Les accidents de la route ont fourni la principale contribution à la charge de traumatismes majeurs supportée par la population. Conclusion Les traumatismes majeurs ont un impact massif sur la santé au niveau de l’individu comme à celui de la population. La plupart des victimes gravement touchées des accidents de la route atteignent l’hôpital et ont de bonnes chances de survivre. Dans le domaine des traumatismes, des politiques de prévention et de soins devraient viser à réduire à la fois le nombre de morts et les séquelles durables pour les survivants. Resumen Carga individual y poblacional de traumatismos graves en los Países Bajos Objetivo Evaluar el impacto de los traumatismos graves en la salud individual y poblacional. Métodos Se emplearon los datos de un registro regional de traumatismos, considerando todos los casos de traumatismos mortales y de lesiones graves no mortales (puntuación de la gravedad > 15) registrados en 1999 y 2000. El impacto de las defunciones se expresó en función de los años de vida perdidos (AVP), y el de los traumatismos graves de los supervivientes, en términos de los años perdidos por discapacidad (APD). La discapacidad se ponderó midiendo la calidad de vida con el cuestionario EuroQol-5D a los 15 meses de ocurrido el traumatismo. Los años de vida ajustados en función de la discapacidad (AVAD) se calcularon sumando AVP y APD. Resultados Se contabilizaron en total 567 muertes y 335 supervivientes. A nivel individual, las muertes por traumatismo (32 AVP por paciente) y los casos no mortales de traumatismo grave (12 APD por paciente) provocaron ambos una pérdida sustancial de años de vida sana. Cada víctima de un traumatismo grave contribuyó con una media de 25 AVAD a la carga de morbilidad. A nivel poblacional, los traumatismos graves causaron 10 AVAD por 1000 habitantes. Las lesiones por accidentes de tránsito fueron el factor que más contribuyó a la carga poblacional de traumatismos graves. Conclusión Tanto a nivel individual como a nivel poblacional, los traumatismos graves tienen un enorme impacto en la salud. La mayoría de las víctimas de accidentes de tránsito con lesiones graves llegan al hospital y tienen bastantes probabilidades de sobrevivir. Las políticas de prevención de los traumatismos y atención traumatológica deberían orientarse a reducir aún más tanto la mortalidad como las secuelas permanentes entre los supervivientes. صخلم ادنلوه في عمتجلماو درفلا لىع ىبركلا حوضرلا نع ةمجانلا ءابعلأا .عمتجلماو درفلا ةحص لىع ىبركلا حوضرلا يرثأت ميـيقت :فدهلا ،حوضرلل يميلقإ لجس نم ةدمتسم تانايب نوثحابلا مدختسا :ةقيرطلا ةميخو تاباصإب اوبيصأ نيذلا ضىرلماو ،حوضرلا نع ةمجانلا تاتاملإا تلمش .2000و 1999 يماع في كلذو ،)15 > ةباصلإا ةماخو ةجرد( ةتيمم يرغ ىدل ةميخولا ةباصلإا نعو ،ةدوقفلما رمعلا تاونسب تاتاملإا يرثأت نع ِّربرُعو زجعلا ةأطو ديدحت في دمُتعاو .زجعلا لظ في اهوشاع يتلا تاونسلاب ينجانلا مادختساب ةساقم ،ةباصلإا عوقو لىع ًارهش 15 رورم دعب ةايحلا ةيعون لىع ددم باستحاب ةححصلما رمعلا تاونس تبسحو .EuroQol-5D نايبتسا في ةشاعلما رمعلا تاونسو ،ةدوقفلما رمعلا تاونس عومجم اهفصوب زجعلا .زجعلا لظ تدأ ،درفلا ىوتسم لىعو .ًايجان 335و ةافو 567 كانه تناك :تادوجولما )ضيرم لكل رمعلا نم ةدوقفم ةنس 32( حوضرلا نع ةمجانلا تاتاملإا ةشاعلما رمعلا تاونس نم ةنس 12( ةميخولا حوضرلل ةتيملما يرغ تلااحلاو .ةَّيحصلا رمعلا تاونسل يربك نادقف ثودح لىإ ،)ضيرم لكل زجعلا لظ في لّدعبم ضيرلما ءبعلا في ىبركلا حوضرلا اياحض نم ةيحض لك مهسأ دقو ىوتسم لىعو .زجعلا ددم باستحاب ةححصلما رمعلا تاونس نم ةنس 25 رمعلا تاونس نم تاونس شرع ةبسنب ىبركلا حوضرلا تببست ،عمتجلما تناكو .ناكسلا نم 1000 لكل كلذو ،زجعلا ددم باستحاب ةححصلما حوضرلا نع مجانلا ءبعلا في بركلأا مهسلما يه ةيرورلما قرطلا ثداوح .عمتجلما لىع ىبركلا درفلا نم لك ىوتسم لىع ميسج يحص رثأ ىبركلا حوضرلل :جاتنتسلاا تامداصت نع ةمجانلا ةميخولا تاباصلإا اياحض مظعم نإو .عمتجلماو .ةاجنلل ةديج صرف مهل حاتتو ،تايفشتسلما لىإ نولصي ةيرورلما قرطلا لىإ حوضرلا ةياعرو تاباصلإا يقوتب ةصاخلا تاسايسلا فدهت نأ يغبنيو .ينجانلا ينب ةئمادلا بقاوعلا فيو ،تاتاملإا في ضفخلا نم ديزم قيقحت Research Burdens of major trauma in the Netherlands 117Bulletin of the World Health Organization | February 2008, 86 (2) Herman R Holtslag et al. 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